Elaine G. Cox

System-Wide Implementation of the Use of an Extended- Infusion Piperacillin/Tazobactam Dosing Strategy: Feasibility of Utilization From a Children's Hospital Perspective

BACKGROUND Use of extended infusions of piperacillin/tazobactam (PT) in adult patients has been described, but data in children are limited. OBJECTIVE The goal of this study was to determine the feasibility of using an extended-infusion PT dosing strategy as the standard of care in a childrens hospital. METHODS This was a prospective observational study of patients aged >30 days who received PT after admission to a freestanding, tertiary care childrens hospital. After institution of an extended-infusion PT dosing protocol as the standard dosing option, patients receiving PT were prospectively assessed for presence of and reasons for changes in dosing regimen. RESULTS A total of 332 patients, with a median age of 5 years (interquartile range, 1.9-12 years) and median weight of 19.9 kg (interquartile range, 11.7 - 37.6 kg) received PT (100 mg/kg based on piperacillin component). Extended-infusion PT was used for the duration of PT therapy in 92% (n = 304) of patients. Twenty-eight patients (8%) received a traditional infusion over 30 minutes, with 19 of 28 being changed from extended infusion and 9 of 28 being empirically prescribed traditional infusion PT. The most commonly encountered reason for not using extended infusions was coadministration of vancomycin (17 of 28 [61%]) and lack of compatibility data with PT. Dosing errors, which were voluntarily reported, were infrequent (1.8% [n = 6]). The few observed dosing errors were likely attributable to the overall ordering process at our institution, which requires ordering as the milligram per kilogram dose as total PT rather than based on piperacillin component as is commonly documented in pediatric dosing references. CONCLUSIONS Results of this study suggest that extended-infusion PT dosing was feasible in this specific childrens hospital. Ninety-two percent of patients received our institutions preferred dosing regimen; a small percentage of patients still needed to receive traditional infusion times.

A Randomized, Controlled Trial of Catheter-Related Infectious Event Rates Using Antibiotic-Impregnated Catheters Versus Conventional Catheters in Pediatric Cardiovascular Surgery Patients

: We conducted a randomized, controlled clinical trial to determine whether a difference in catheter-associated blood stream infection (CABSI) incidence existed between children who underwent cardiac surgery and had a central venous catheter impregnated with minocycline and rifampin versus those who had a conventional, nonimpregnated catheter after cardiac surgery. Due to a lower number of infections than expected, the study was terminated early. Among 288 evaluable patients, the rates of CABSI and line-related complications were similar between the 2 groups.

Conversion of a single-facility pediatric antimicrobial stewardship program to multi-facility application with computerized provider order entry and clinical decision support.

OBJECTIVE Antimicrobial stewardship programs (ASPs) help meet quality and safety goals with regard to antimicrobial use. Prior to CPOE implementation, the ASP at our pediatric tertiary hospital developed a paper-based order set containing recommendations for optimization of dosing. In adapting our ASP for CPOE, we aimed to preserve consistency in our ASP recommendations and expand ASP expertise to other hospitals in our health system. METHODS Nine hospitals in our health system adopted pediatric CPOE and share a common domain (Cerner Millenium). ASP clinicians developed sixty individual electronic order sets (vendor reference PowerPlans) to be used independently or as part of larger electronic order sets. Analysis of incidents reported during CPOE implementation and medication variances reports was used to determine the effectiveness of the ASP adaptation. RESULTS 769 unique PowerPlans were used 15,889 times in the first 30 days after CPOE implementation. Of these, 43 were PowerPlans included in the ASP design and were used a total of 1149 times (7.2% of all orders). During CPOE implementation, 437 incidents were documented, 1.1% of which were associated with ASP content or workflow. Additionally, analysis of medication variance following CPOE implementation showed that ASP errors accounted for 2.9% of total medication variances. DISCUSSION ASP content and workflow accounted for proportionally fewer incidents than expected as compared to equally complex and frequently used CPOE content. CONCLUSION Well-defined ASP recommendations and modular design strengthened successful CPOE implementation, as well as the adoption of specialized pediatric ASP expertise with other facilities.

Acquired Toxoplasmosis After Orthotopic Heart Transplantation in a Sulfonamide-Allergic Patient

We report the case of a young adult with a history of an allergic reaction to a sulfonamide antibiotic who developed toxoplasmosis after his second orthotopic heart transplant. As a result of this drug allergy, the patient did not receive prophylaxis with trimethoprim and sulfamethoxazole. He was successfully treated with clindamycin, pyrimethamine, and folic acid.

Efficacy of limited cefuroxime prophylaxis in pediatric patients after cardiovascular surgery.

PURPOSE. The efficacy of limited cefuroxime prophylaxis in pediatric patients after cardiovascular surgery was evaluated. METHODS. All patients age 18 years or younger who underwent cardiovascular surgery and received postoperative care from the cardiovascular surgery team between February and July 2006 (preintervention group) and between August 2006 and January 2007 (postintervention group) were eligible for study inclusion. Patients were excluded if they did not receive cefuroxime as postoperative prophylaxis, had a preexisting infection, underwent cardiac transplantation or extracorporeal membrane oxygenation, or underwent delayed sternal closure. The preintervention group received prolonged cefuroxime prophylaxis, and the postintervention group received 24 hours of cefuroxime prophylaxis. Data collected included patient demographics and clinical and laboratory markers of infection, as well as microbiological evidence of and treatment courses for documented or presumed infections. RESULTS. A total of 210 patients were enrolled in the study. The number of patients who required additional antibiotics for suspicion of clinical infection did not significantly differ between the preintervention and postintervention groups (18.6% versus 26.9%, respectively), nor did the rate of documented infection (bacteremia, urinary tract infection, endocarditis, sepsis) (42.1% versus 48.3%, respectively). Moreover, indications for the antibiotics initiated were similar between the preintervention and postintervention groups. Clinical and laboratory signs of postoperative infection were similar between groups. There were no differences in postoperative white blood cell counts, peak serum glucose levels, and platelet nadir between groups. CONCLUSION. Limiting postoperative cefuroxime prophylaxis to 24 hours did not increase infectious outcomes in pediatric patients.

Survey of Congenital Heart Surgeons’ Preferences for Antimicrobial Prophylaxis for Pediatric Cardiac Surgery Patients

Patients with congenital heart defects are a unique population with generally immature immune systems. Fragility in the postoperative period may contribute to surgical site infections (SSIs), a life threatening complication for this population. The need for postoperative antimicrobial prophylaxis

Implementing Extended-Infusion Cefepime as Standard of Care in a Children’s Hospital A Prospective Descriptive Study

Background: Extended-infusion cefepime (EIC) has been associated with decreased mortality in adults, but to our knowledge, there are no studies in children. Objective: The objective of this study was to determine the feasibility of implementing EIC as the standard dosing strategy in a pediatric population. Methods: This was a descriptive study of children aged 1 month to 17 years, including patients in the intensive care unit, who received cefepime after admission to a freestanding, tertiary care children’s hospital. Patients were excluded if they were admitted to the neonatal intensive care unit or received cefepime in the outpatient, operating, or emergency department areas. Demographic and clinical data for patients who received cefepime from April through August 2013, the period following EIC implementation, were extracted from the medical records. Results: A total of 150 patients were included in the study, with a median age (interquartile range [IQR]) of 6 years (2-12.3 years) and median weight (IQR) of 20.7 kg (13.2-42.8 kg); 143 patients received cefepime via extended infusions, and 10 (7.0%) of those were changed to a 30-minute infusion during treatment. The most common reasons for infusion time change were intravenous (IV) incompatibility and IV access concerns, responsible for 50% of changes. Dosing errors and reported incidents during therapy were sparse (n = 12, 8.0%) and were most commonly related to renal dosing errors and/or initial dose error by prescriber. Conclusions: Because 93.0% of the patients who initially received EIC remained on EIC, implementation of EIC as the standard dosing strategy was feasible in this pediatric hospital.

Acute deafness as the presenting symptom of bacterial meningitis

Hearing loss has long been documented to occur during the course of meningitis. We report a case of a child presenting with deafness as the principal complaint of bacterial meningitis.

Attempts to change culture in a line-obsessed pediatric world: The Riley Heart Center line initiative

Interventions to reduce central line-associated bloodstream infections in pediatric patients have not yet been validated. Unique approaches to reducing infection rates may be warranted in this population.

Linezolid-Associated Thrombocytopenia in Children With Renal Impairment

Impaired renal function has been associated with an increased risk of thrombocytopenia in adults receiving linezolid. Findings from this retrospective cohort demonstrate an association between thrombocytopenia and lower creatinine clearance in children receiving linezolid.